Improving the “patient experience” is a trending topic in health policy circles these days, the subject of many new conferences and journal articles. Providers puzzle over this. How can they improve patient “compliance” and “adherence” to doctor’s orders? What are the techniques to educate patients on “self-management”? How can we better coordinate the various services offered to each patient so the patient doesn’t fall through the cracks?

It is gratifying to see this emphasis on patients. Yet many providers still do not grasp that improving patient experience requires something more than studying the issue and implementing a few new policies. It requires nothing short of a paradigm shift in the way they think about their role in the patient’s life and the fundamentals of their practice.

The best example of providers misunderstanding the depth of this issue is how the influential provider-governed Beryl Institute defines the patient experience: “the sum of all interactions, shaped by an organization’s culture that influence patient perceptions across the continuum of care.” In other words, Beryl believes that the patient experience is the patient’s reaction to what providers do.

Trust me, that is not how patients view their own experience.

“Momma had her last radiation treatment today,” a young woman I’ll call Karen posted on Facebook last June. “Can’t even explain the amount of strength and courage that crazy lady has shown and I couldn’t be more proud to call her my Mom.”

Patients and their families see their experiences as Karen did, as the act of summoning every last reserve of strength and courage to endure each minute, one day at a time. Patients don’t see themselves as mere recipients of services. Patients and their families don’t talk about self-management or compliance or adherence. They find themselves in an epic story of survival and adventure. They are the reluctant heroes of that personal drama, Odysseus setting forth on the ultimate journey. Some patients are ready and some aren’t, but every patient is forced to try their best, since the road is before them.

One of the country’s leading thinkers on the patient experience is Dave deBronkart, who miraculously survived Stage 4 kidney cancer. His mantra (and the title of the book he coauthored): “Let Patients Help.” DeBronkart advises providers to recognize patients as journeymen, not baggage, in the quest toward recovery. He speaks to provider groups throughout the world, and gave one of the most popular TED talks ever, all with an eye toward reframing the way the health care system engages patients and insisting that patients are part of the cure, not passive recipients of care. He says that patient knowledge and wisdom and willingness to research are a wealth of untapped resources.

Most of us know someone like Karen, Karen’s mom or Dave, who stood up and squarely faced the worst news imaginable. Though doctors work with patients every day, there is something very different about being on the other side of the fence, as deBronkart’s co-author Dr. Danny Sands movingly recounts in his blog about suffering life-threatening seizures.

Providers can nurture, coach, mentor, guide and be humble enough to realize they have only a small – though critical – role to play in the larger life story of the human beings they call patients. Providers succeed when they recognize they aren’t treating a disease or filling an empty vessel with “services,” but coaching a complex person with a destiny and a legacy who, for better or worse, is the hero of her own life.

I’m sad to report that Karen’s “crazy lady” mother, Susan, 52, died from breast cancer a few days ago. Susan was beloved throughout her rural Maine community, an exceptional teacher, community volunteer, mother. She had a very special gift with children, many of whom are traveling from far and wide to come to the funeral of this woman they revered.

“I believed a miracle would happen and she would beat this beast,” said Susan’s dear friend Kathleen, “She fought the most courageous fight I’ve ever witnessed. Heaven is so lucky to have this new angel.”

In my opinion, Susan did win, though not the way we all hoped for. But a life well-lived is the ultimate triumph. “To have been given 22 years with you was such a blessing.” Karen wrote in an open letter the day her mother died. “I promise with all my heart to be the fun loving, positive and slightly wacky person you’ve taught me to be. Thank you for all the amazing memories Momma Bear.”

Susan’s a winner and so are the many excellent physicians and nurses who cared for her through her battle with cancer. As the famous doctor Patch Adams once said, “You treat a disease, you win, you lose. You treat a person, I guarantee you’ll win.” The patient experience is more the stuff of Shakespeare than Gray’s Anatomy. Providers with that wisdom will transform health care forever.

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

Identifying high-risk patients early

Educating the patient and involving family members

Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

(Reuters Health) – Close to one-quarter of colonoscopies performed on older adults in the U.S. may be uncalled for based on screening guidelines, a new study from Texas suggests.

Researchers found rates of inappropriate testing varied widely by doctor. Some did more than 40 percent of their colonoscopies on patients who were likely too old to benefit or who’d had a recent negative screening test and weren’t due for another.

Guidelines from the U.S. Preventive Services Task Force, a government-backed panel, recommend screening for colon cancer – every 10 years, if it’s done with colonoscopy – between age 50 and 75.

After that point, “It involves an unnecessary risk with no added benefit for these older patients,” said Kristin Sheffield, the new study’s lead author from the University of Texas Medical Branch in Galveston.

Those risks include bowel perforation, bleeding and incontinence, as well as the chance of having a false positive test and receiving unnecessary treatment.

Even for screening tests that are universally recommended for middle-aged adults, the balance of benefits and risks eventually points away from screening as people age. Any cancers that are caught might never have shown up during a patient’s lifetime if the person is too old or the cancer too slow-growing.

But because there has been so much effort to educate the public about reasons to get screened, the potential harms are often overlooked – and the idea of stopping screening isn’t regularly discussed, researchers said.

Sheffield and her colleagues looked at Medicare claims data for all of Texas and found just over 23 percent of colonoscopies performed on people age 70 and older were possibly inappropriate.

For patients age 76 to 85, as many as 39 percent of the tests were uncalled for, the researchers wrote Monday in JAMA Internal Medicine. The rest were likely done for diagnostic purposes.

A MORAL OBLIGATION?

Another study published in the same journal supports the idea that many Americans are so focused on the possible benefits of screening that they don’t realize harms are involved as well.

Dr. Alexia Torke from the Indiana University School of Medicine in Indianapolis and her colleagues surveyed 33 adults between age 63 and 91 and found many saw screening as a moral obligation.

Few of the older adults had discussed the possibility of stopping routine screening, such as for breast cancer, with their doctor, and some told the researchers they would distrust or question a doctor who recommended they stop.

“There’s very limited data for any cancer test that it leads to any benefit for older adults,” said Dr. Mara Schonberg, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

“You want to be doing this thinking it’s going to be helping you live longer,” she told Reuters Health – especially because the chance of suffering side effects from screening or treatment may be higher among older people.

Schonberg, who wrote a commentary on Torke’s study, said time spent unnecessarily screening older adults may take away from conversations that could actually benefit their health – such as about exercise and eating better.

“There’s really a strongly held belief that you need to get screened, that it’s irresponsible if you don’t,” said Dr. Steven Woloshin, who has studied attitudes toward screening at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

“There have been all these messages for years about the importance of screening that people have been inundated with, and I think it’s really hard to change the message now, even though it’s become clear that screening is a double-edged sword,” Woloshin, who wasn’t involved in the new research, told Reuters Health.

The researchers agreed screening should be an individual decision as people get older, but that everyone should fully understand what they stand to gain – if anything – and what they could lose by getting screened.

For colon cancer in particular, Sheffield recommended elderly people who really want to be screened go with a less-invasive method than colonoscopy, such as fecal occult blood testing.

OVERUSING ANESTHESIA?

In another analysis of Medicare beneficiaries undergoing colonoscopy, researchers led by Dr. Gregory Cooper from Case Western Reserve University in Cleveland learned the proportion of procedures using anesthesia – most likely propofol – increased from less than nine percent in 2000 to 35 percent in 2009.

The cost of a procedure using anesthesia is about 20 percent higher than one without it, the researchers noted.

Patients in their study suffered a complication – including perforation or breathing problems – during one in 455 procedures using anesthesia, compared to one in 625 without anesthesia. The researchers said so-called deep sedation may impair patients’ airway reflexes and blunt their ability to respond to procedure-related pain.

The Agency for Healthcare Research and Quality (AHRQ) has identified the top 10 patient safety strategies (PSSs) ready for immediate use. Paul G. Shekelle, MD, PhD, from the RAND Corporation, Santa Monica, California, and colleagues present the list in a special supplement to the Annals of Internal Medicine published online March 4. These interventions, if widely implemented, could dramatically enhance patient safety and save lives by reducing medication errors, bed sores, and healthcare-associated infections.

“Wide-scale reductions in patient harm have been modest despite over a decade of research, improvement, and effort since the Institute of Medicine’s ‘To Err is Human’ report,” Patrick W. Brady, MD, told Medscape Medical News in an email interview. “Since that report, the evidence base for safety strategies has continued to grow, but great challenges exist in taking these strategies to scale throughout health systems,” said Dr. Brady, an assistant professor in the Division of Hospital Medicine and the James M. Anderson Center for Health Systems Excellence, Department of Pediatrics, University of Cincinnati, Ohio, who was not involved in the AHRQ project.

According to a journal news release, diagnostic errors result in between 44,000 and 80,000 annual deaths in the United States alone, and bed sores lead to another 68,000 deaths. Thousands more patients die each year as a result of communication errors or failure to receive evidence-based interventions.

During the last 4 years, Dr. Shekelle and colleagues conducted an evidence based assessment of PSSs, including 79 strategies identified in the 2001 AHRQ report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices. On the basis of that assessment and subsequent input from clinicians, researchers, and policymakers regarding the epidemiology of errors and preventable harms, the investigators identified the top 10 PSSs, as well as 31 additional PSSs.

“The team of patient safety experts who put this list together are among the most respected safety experts in the world,” Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, told Medscape Medical News in an email interview. “The strategies they have identified are effective, important, and should be on the top of every healthcare leader’s list for consideration.”

AHRQ’s Top 10 Patient Safety Strategies

preoperative and anesthesia checklists to reduce operative and postoperative events;

bundles including checklists to reduce septicemia associated with central lines;

“It is as important for hospital and health system leaders to know why some strategies are not on the list as to know what is on the list,” Foster said, wondering about the absence from the list of adoption of electronic health records despite robust decision support. “Is the evidence still emerging? Were they concerned about emerging evidence of some of the risks from use of [electronic health records]?”

Dr. Brady largely agreed with the list but noted that it could be the “source of some spirited debate.” He commended AHRQ for recommending strategies supported by excellent systematic review and/or research designs including randomized trials and comparative effectiveness studies.

“The considerations used by the authors [regarding] scope of problem addressed, strength of evidence of strategy effectiveness, potential for unintended consequences, cost, and difficulty of implementation are logical and will advance the field of patient safety science,” Dr. Brady said.

Implications for Patient Safety

Foster identified 3 challenges to finding the underlying causes of medical errors and strategies for reducing them: budget cuts affecting AHRQ research, rarity of some errors hindering determination of causes and solutions, and multiple causes underlying some errors, which necessitate use of bundled strategies.

“Medical errors are a worldwide problem that can affect many, many patients and their families, and the AHRQ has safety research as one of its missions, but its entire budget is miniscule compared to that of [the National Institutes of Health], and within AHRQ, patient safety is…only one of the important components,” Foster said. “If we want to resolve the problem, we need a sustained and significant investment in patient safety research, which would mean increasing AHRQ’s budget even in this era of federal budget cuts.”

The payoff could be dramatic. The American Hospital Association recently reported that their Hospital Engagement Network of nearly 1600 hospitals had a 40% reduction in central line bloodstream infections using the bundle recommended by AHRQ, and preliminary results on the implementation of the catheter-associated bloodstream prevention bundle appear to be equally promising.

Barriers to improving patient safety may include failure of health systems to implement complex, behavior-based interventions, as influenced by organizational leadership and culture. Dr. Brady recommends additional research in this area.

“An additional challenge to the successful implementation of safety strategies at individual hospitals may be the increasingly long list of ideas to improve patient safety,” Dr. Brady noted. “As this field has no shortage of good ideas, it may be challenging for hospital boards and patient safety leaders to determine where to focus. This rigorously developed, evidence-based top 10 is an important step to help healthcare administrators, clinicians, and researchers best target their efforts to improve patient safety now.”

“Fundamentally, we need to know more about what causes harm to patients and which strategies are effective in preventing them,” Foster concluded.

The AHRQ supported development of their report. Dr. Brady and Foster have disclosed no relevant financial relationships. Some of the report and editorial authors have disclosures involving the National Institutes of Health Research Collaborations for Leadership in Applied Health Research and Care for Birmingham and the Black Country; ECRI Institute; Veterans Affairs; AHRQ; Centers for Medicare & Medicaid Services; National Institute of Nursing Research, Office of the National Coordinator; UpToDate; Cantel Medical Group; Association for Professionals in Infection Control and Epidemiology, Hospitals and Health Care Systems; National Institutes of Health; Leigh Bureau; Penguin Group; American Board of Internal Medicine, Salem Hospital; Lippincott, Williams & Wilkins, McGraw-Hill; QuantiaMD; PatientSafe Solutions, CRISI, EarlySense; John Wiley and Sons; Marc and Lynne Benioff; United States–United Kingdom Fulbright Commission; RAND Corporation; and/or more than 100 other healthcare organizations including hospitals, healthcare systems, and state medical and hospital associations. Full conflict-of-interest information is available on the journal’s Web site.

If you think that medical errors are a thing of the past, you are mistaken.

It has been 14 years since the Institute of Medicine’s report “To Err Is Human” shattered the myth that most, if not all, physicians are all-knowing practitioners with flawless skills and infallible judgment.

The story of what happened in the report’s wake was predictable:

Where the healthcare industry failed to act as it should have, the federal government and accrediting organizations stepped in to set the standards for healthcare quality and safety, establish quality measures, and assure that healthcare delivery entities complied by instituting financial and other penalties for poor performance.

Patients who previously felt safe began to question their healthcare providers.

We began to see some evidence of improvement in the quality and safety of healthcare services across the U.S.

In light of the foregoing, a recent “trip” to the website for American Medical News, the newspaper of the American Medical Association, left me feeling frustrated and sad.

A story by Kevin B. O’Reilly referred to a recent well-referenced article in Surgery, noting that, at the close of last year, “never events” continue to occur in U.S. operating rooms 80 times per week.

In addition to causing temporary or permanent harm to patients, he extrapolated that these events carry a financial burden of almost $1.3 billion over 20 years.

Although surgical “never events” are rare (i.e., one in every ~12,000 procedures), their seriousness should not be diminished — especially when simple checklists and protocols have been shown to reduce the occurrence of such mistakes to near zero.

According to the article, published findings of a review of medical liability settlements and judgments collected in the National Practitioner Data Bank for 1990 to 2010 revealed that surgeons of all ages are involved in “never events” such as inadvertently leaving surgical items in the patient, performing either the wrong procedure or the right procedure on the wrong site, and — most egregious of all — operating on the wrong patient.

Startling as this is, previous studies have found that the 90% of injured patients who do not receive indemnity payments are not even included in the data bank.

Other studies have shown that “never events” can be eliminated — or at least minimized — by intensifying focus on identifying and correcting deficient processes, for example by addressing communication lapses with presurgery briefings and marking operative sites.

To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.

After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.

A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.

Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.

Because patient safety is part and parcel of my daily routine — whether in the hospital, the classroom, or at a national meeting — I ask myself why our industry is not mortified and why, as a nation, we are not appalled.

When I look to the airline industry for analogies, as I often do, the Boeing 787 “Dreamliner” comes to mind.

After only a couple of incidents, the federal government grounded this newest, most technically sophisticated airliner until the problem was fully understood, the deficiency corrected, and the risk to passengers and crew minimized.

Shouldn’t we address surgical “never events”, which affect 4,160 patients each year, with the same urgency and gravity that we address the potential risk to 210-270 passengers of travelling in the “Dreamliner”?

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Those are some of the findings from a survey of 900 practicing registered nurses by the ANA and GE Healthcare. The survey, which queried 500 nurses in the United States, 200 in the United Kingdom, and 200 in China, finds that few nurses would call their hospitals “safe.”

One of the most striking findings is the apparent chasm between the existence of hospital patient safety programs and their perceived effectiveness. For example, 94% of nurses surveyed say that their hospitals have programs in place that promote patient safety, which on the surface is great news; these programs are probably something that the execs at these institutions brag about.

However, nurses—90% of whom consider themselves most responsible for patient safety, over physicians (69%) and patient safety officers (60%)—don’t seem enthusiastic about the effectiveness of their hospital’s patient safety programs.

Only 41% of nurses describe the hospital they work in as “safe.” Just over half of nurses (57%) believe that the patient safety programs in their hospital are effective.

Whether these programs exist doesn’t seem to affect nurses’ perceptions of patient safety as much as the factors that affect how the programs are actually put in to practice. For example, in theory, patient safety programs might rely on error reporting and discussing these errors as a team.

In practice, however, error reporting often doesn’t occur because nurses are afraid they’ll be penalized for making mistakes. The survey found that although 90% of nurses say it’s important to have a culture where nurses are not penalized for reporting errors or near misses, 59% agree that nurses often hold back reporting patient errors in fear of punishment. Most nurses (62%) say the same about reporting near-misses.

Another key component of patient safety is open communication between nurses and their peers (and their leaders); nurses and physicians; and hospitals and patients.

But again, nurses identify a gap between theory and practice. Despite the prevalence of patient safety programs—and the communication that those programs presumably encourage—just 37% of nurses rated their hospital as excellent at communication with the patient. Even fewer nurses (31%) say their hospital is excellent at communication between staff.

For example, 33% of nurses said that that “poor communication among nurses at handoff” is something that has increased the risk of patient safety incidences in their hospital in the past 12 months, and 31% said “poor communication with doctors” has also increased the risk of patient safety incidents.

Another area where nurses crave more communication is technology. The survey finds that 74% of nurses say that technology/software patient safety initiatives exist in their hospitals. Although 59% of nurses say that patient safety data is collected and reported, they also say that there’s no follow-up or feedback given to the nurses.

Taken as a whole, these results seem to indicate that nurse leaders need to make a greater effort to really engage bedside nurses in patient safety initiatives, from development to implementation. Nurse leaders and executives should remember what Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance, told me recently:

“There’re some incredibly creative and innovative bedside nurses in each and every organization. I’m always amazed at the ideas and the strategies that they’re even able to bring forward themselves; how to make something better.”

I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland. This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test. –oma is the suffix used in the name of any tumor or enlargement. Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen. Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.

Small ovarian cysts seen on pelvic ultrasound. The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern. Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.

Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors. They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.

Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing. The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests. When abnormal these are usually repeated along with testing for viral hepatitis C and B. If they remain abnormal liver imaging, sometimes liver biopsy are often done. The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight. This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

The 1,782 page Francis report into the Mid Staffs tragedy is a mass of detail. Hugely disturbing detail, you can’t fail to be moved by the evidence. But Francis, perhaps because he has a legal mind, doesn’t get behind the facts; he doesn’t question assumptions, he doesn’t even open the door to matters of theory.

As a consequence his recommendations represent what we would call single-loop thinking. The NHS is subject to massive amounts of regulation, but Francis recommends more, wrong thing righter. He recommends a ‘zero tolerance’ approach to breaches of fundamental standards but doesn’t question why the system as currently managed, might produce such neglect. He calls for a culture that puts patients first, but doesn’t consider why the current system fails in this regard.

If it is true that we have reached a level of dystopia that requires us to articulate a ‘structure of clearly understood fundamental standards’ – his top recommendation – we should despair. He thinks inspection for compliance will drive sufficient fear amongst healthcare professionals, yet he points to the fear culture that is already pervasive and dysfunctional. He argues for openness and transparency but fails to understand that the current use of gagging clauses (which he says should be banned) and shocking treatment of treatment of whistle-blowers is, too, symptomatic of the culture of fear. He does nothing to explain the reasons we have a culture of fear.

Francis thinks the answer is training, failing to appreciate how the current system drives peoples’ behaviour. He thinks that better leadership will instil a better culture, without understanding what currently drives leaders’ behaviour. Like Ed Balls did with social care, he recommends the creation of a leadership college, as though we can train that too. He thinks better information and benchmarking will act as a stimulus to improvement, showing no understanding of how benchmarking will lead to mediocrity, not innovation. It is perhaps ironic that the Francis recommendations on health improvement treat the symptoms, not the causes.

When Francis gets close to the causes: acknowledging a form-filling, target- and cost-driven culture, he fails to question them. He cannot see that form-filling bears no relation to and will detract from quality, he doesn’t know what targets do to systems and why, he wouldn’t believe that a focus on costs is driving costs up. Francis has a legal mind. He gave us the facts. You should read his report; you will be moved.

Politicians move in

The minister for health, Jeremy Hunt, takes up the Francis theme on excessive box-ticking, bureaucracy and burdensome regulation by announcing a talking-shop whose purpose is to reduce the regulatory burden by a third. I can hear Deming in my head: ‘why a third? Is it the right third? Why is it not two thirds? What benefit ensues against the cost of compliance? The best we can expect is less of the wrong thing; that’s still the wrong thing.

The right way to have gone would have been to order all leaders in the NHS to review their box-ticking and form-filling to ask: what of any of this is important to us in understanding and improving healthcare? And thus NHS leaders would make their own decisions about changing the nature of control and, as a necessary and urgent consequence, the nature of regulation.

The minister says we need a culture that puts the patient first, not knowing how the current system obviates any attempt to do that and announced a review of complaints procedures. You couldn’t make it up really; it is as though he read the Beano guide to management.

The prime minister, David Cameron, strides in with announcements about handing the Francis report to the police in order to find people to blame, giving performance-related-pay to nurses, sacking the bad ‘uns and making nurses fill in forms to prove they have spoken to every patient every hour. Clueless, wrong and damaging.

In short, while the minister promises to remove the dead hand of micro-management from crushing people, the hand is, in fact, warming up for BOHICA (bend over, here it comes again).

Closing one of his presentations with a literary flourish, the minister said: “Let me finish with words from TS Eliot we should not forget, when he said, “It is impossible to design a system so perfect that no one needs to be good.”

I’m no literary expert, but when I read Eliot’s ‘Choruses from the Rock’, I experience a man regretting society’s alienation from God; in the NHS, alienation from a worthy purpose:

‘What have we to do but stand with empty hands and palms turned upwards in an age which advances progressively backwards?’

Eliot (writing in 1934) describes how man is facing a tremendous flood of meaninglessness because context has been removed. Man has created an artificial world based on the new gods of reason, money and power. This is what has happened in health, the minister and his predecessors are responsible for a system that worships false gods.

It’s the system, stupid

I went to be a ‘witness’ on the Moral Maze (Radio 4) to try my best to make this point. We have a choice: to run our organisations in ways that encourage bad behavior, or in ways that encourage good; behaviour is a product of the system. I say ‘try’ because, for those of you who don’t know, the Moral Maze is something of a bear-pit. Ex minister Michael Portillo was my ‘opponent’ – an intelligent man who, nevertheless, thinks a bit of fear is a good thing. Having roughed me up he was at least decent enough to acknowledge my arguments in the summing up.

Don Berwick is a world authority on patient safety. For two decades he led the US Institute for Health Improvement and he led the US president’s “Obamacare” reforms. In 2011 was forced to resign that post, partly for referring to the NHS as an example for the US to follow.

In 2008 he was quietly commissioned to report on the culture of the NHS by the then Chief Medical Officer Liam Donaldson. He reported a climate of “fear” but this did not become public until the Francis Inquiry into the Mid Staffordshire scandal.

Last month David Cameron announced Don Berwick had been asked to become NHS Patient Safety Tsar to lead a panel “to make zero harm a reality in our NHS”. Don’t be surprised if their recommendations run counter to the government’s ‘reform’ agenda.

In July 2008 Don Berwick wrote a 60th birthday message to the NHS in the British Medical Journal. In it he made ten suggestions for improving the NHS. His advice was so good, and so prefigures the Francis Report, that I thought I’d share it.

“First, put the patient at the center – at the absolute center of your system of care”. Berwick argues for “the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself” rather than any reliance on focus groups or surveys.

“Second, stop restructuring.” In an echo of Francis he warns that it is destructive of time and confidence and leads to risk averse healthcare. Stability, he says, helps change “become easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.”

“Third, strengthen the local health care systems – community care systems – as a whole.” Health economies, not the fragmentation into individual elements like hospitals, clinics, surgeries, should become the “core of design”.

“Fourth, to help do that, reinvest in general practice and primary care”. Berwick describes general practice, not the hospital, as “the jewel in the crown of the NHS”.

“Fifth, please don’t put your faith in market forces.” I’m not sure David Cameron read this bit before appointing him. Berwick scathingly says: “It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can. I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. “

“Sixth, avoid supply-driven care like the plague.” He warns, rightly, that the pursuit of institutional self-interest has helped make healthcare unaffordable in the USA

“Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality.” He warned we needed a coherent system of “aim-setting, oversight, and assistance.” As Francis also discovered.

“Eighth, heal the divide among the professions, the managers, and the government.” This was another theme of the Mid Staffs report, made much worse by the rise of “general management” after the Griffiths Report of 1983. Berwick warned, again echoed by Francis, that “the NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers and public servants, on the other hand.”

“Ninth, train your health care workforce for the future, not the past.” The new skills we need are those in “patient safety, continual improvement, teamwork, measurement, and patient-centered care”.

“Tenth, and finally, aim for health.” He warns that “great health care, technically delimited, cannot alone produce great health”, and goes on: “Developed nations that forget that suffer the embarrassment of growing investments in health care with declining indices of health. The charismatic epidemics of SARS, mad cow, and influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance abuse, and physical inactivity.”

Don Berwick concluded the article by writing: “The only sentiment that exceeds my admiration for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun. I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just. Happy birthday!”

Don Berwick’s own publications are a joy to read. You can also hear him in these two short videos. The first, ironically, was posted by an American free market think tank aiming to discredit him as being too left wing: it is indeed a brilliant two-minute defence of the NHS. The second summarises some key themes for good healthcare.

In commercial aviation, the last passenger fatality on a large U.S. jet was more than a decade ago. In health care, there may be as many as 200,000 preventable deaths each year in this country alone. We must stop thinking of these as unavoidable, and instead think of them as unimaginable.

Long before I became known for the Hudson River landing of US Airways Flight 1549, I had spent my professional life becoming expert at the science of safety. Decades in the cockpit, combined with years of airline safety work as an accident investigator and an airline crew instructor, taught me that good outcomes are the result of reliable systems, good leadership, consistent use of best practices, clear communication – and years of preparation. It doesn’t matter if your domain is the cockpit or the operating room: safety requires a system and a culture that must be learned and practiced by every member of the team. And that is why I so strongly believe that there is much our health care system can learn from the impressive system and culture of safety that have been developed in the airline industry.

How can two seemingly disparate worlds be connected? Consider that aviation and health care are both high-risk, complex, evidence-based domains that require high-level human performance. Now contrast the safety records of these two fields. In commercial aviation, the last passenger fatality on a large U.S. jet was in November 2001, more than a decade ago. Not so in health care. As we know from the Institute of Medicine reports and others, there may be as many as 200,000 preventable deaths each year in this country alone, including deaths resulting from what are considered to be medical errors – but are really system failures – and health-care-associated conditions. That’s the equivalent of 20 large jetliners crashing a week with no survivors, nearly 3 a day. After about the second day, we would see what we had after September 11, 2001 – a nationwide ground stop. There would be a Presidential commission, Congressional hearings; the National Transportation Safety Board (NTSB) would search out causes. No one would fly until we had solved the problems. Because airline accidents are very rare, they involve many people at once, they are noteworthy and newsworthy, we have achieved in aviation the public awareness and the political will to act. And that’s what’s lacking currently in medicine, along with leadership and direction, and a real sense of urgency, to address a problem that is systemic, huge and immediate. There are many who still think of these deaths as an unavoidable consequence of providing care. We must stop thinking of them as unavoidable, and instead think of them as unimaginable.

One remedy would be the establishment of an entity like the NTSB to investigate select, representative medical failures. (See An NTSB for Health Care — Learning From Innovation: Debate and Innovate or Capitulate). This, I believe, would help move medicine from the current blame-based system to a learning-based system in which accountability and learning are fairly and accurately balanced, and people feel free to report not only their own mistakes but system deficiencies that might lead to an accident. Through the NTSB the aviation industry has a formal lessons learned process. It comes up with probable causes and contributing factors. It makes recommendations to the rule makers and the industry about how to prevent a recurrence. This information is globally disseminated, but locally actionable.

Another remedy is to change the culture involving what I call human skills. In the old days of aviation, captains could be gods and cowboys. They often ruled their cockpits by whim, according to idiosyncrasies and preferences, with little consideration of best practices. If someone spoke to a captain about an unsafe practice, they put their jobs on the line. Thankfully, those days are long gone. We have achieved much better standardization; we have taught captains that they have to be the builders and leaders of teams; we set the tone, we create an environment of psychological safety, where there are no stupid questions, where we create a shared sense of responsibility for the outcome. It’s not about who’s right, it’s about what’s right. And paradoxically, it’s this reliability, this standardization of processes that becomes the firm base on which we can innovate when we face the unexpected. That’s what my crew and I did on Flight 1549. This was something we never trained for, it was something we had never envisioned, and we had 208 seconds to solve this life-threatening problem we had never seen before.

For more than a hundred years now, we have been learning important lessons at great cost, many of them literally bought in blood. Almost everything we know in aviation, every procedure, every rule, we have because people have died. All these lessons that have finally made aviation so ultra-safe, we are now offering up to medicine for the taking.

What would it take for health care systems to adopt some of the practices of aviation? If there were a national reporting agency for medical errors and near misses, would you be more likely to report? Tell us what you think in the Comment box below.

Best known as the hero pilot from the “Miracle on the Hudson,” Chesley B. “Sully” Sullenberger III has been dedicated to the pursuit of safety for his entire adult life. An aviation safety expert and accident investigator, Mr. Sullenberger serves as a CBS News Aviation and Safety Expert, as well as founder and chief executive officer of Safety Reliability Methods, Inc., a company dedicated to management, safety, performance, and reliability consulting. He is also on the editorial board of the Journal of Patient Safety and a member of the Greenlight Group, a team of world class experts supporting a number of global health care research and development initiatives.

Harlan Krumholz and colleagues published a JAMA article last month that examines the correlation between risk-adjusted, 30-day readmission rates and mortality rates, both calculated on a fee-for-service Medicare cohort using CMS’s methodology. In particular, they examined patients discharged with a diagnosis of heart failure (HF), acute myocardial infarction (AMI), or pneumonia (PN). Correlations were not statistically significantly different from zero between mortality and readmission rates for the AMI and PN disease cohorts. For the HF cohort, the correlation point estimate was -0.17. Wanna see it?

(Dashed lines are medians. The blue line is a cubic spline smooth regression. The shaded area designates the 95% confidence interval.)

From a policy perspective, the independence of the measures is important. A strong inverse relationship might have implied that institutions would need to choose which measure to address. Our findings indicate that many institutions do well on mortality and readmission and that performance on one does not dictate performance on the other.

Ashish Jha has another perspective. A quote doesn’t do justice to his argument, but here’s the key passage:

So if one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).

Ashish goes on to suggest readmission rates can still play a helpful role in motivating hospitals and health systems to improve. Maybe! I worry that they can also be gamed. Since they’re hardly correlated with mortality, we may not easily detect when they are.